Child Psychiatric Patients Affected by Intimate Partner Violence
and Child Abuse – Disclosure, Prevalence and Consequences
Ole Hultmann
Doctoral Dissertation in Psychology Department of Psychology University of Gothenburg, 2015 © Ole Hultmann Department of Psychology University of Gothenburg, 2015 Printing: Ineko, Sweden, 2015 Front page illustration: Leif Samuelsson
ISSN 1101-718X Avhandling/Göteborgs universitet, Psykologiska inst. ISRN GU/PSYK/AVH--327—SE
Abstract
The overall aims of this thesis were (1) to document the prevalence of child abuse and exposure to intimate partner violence (IPV) among child and adolescent mental health care (CAM) patients, (2) to study the clinicians’ attitudes towards asking routinely about IPV, (3) to compare psychiatric symptoms between patients with (a) experience of family violence (child abuse and/or exposure to IPV) (b) experience of violence outside the family and (c) patients with no such experiences, and (4) compare psychiatric symptoms between patients who had both witnessed IPV and been subjected to child abuse with those either subjected to child abuse or those who had witnessed IPV, but not both. An additional aim in study IV was to explore the importance of concordance/discordance between children’s and parents’ reports of occurrence of IPV. Data for the studies were collected among 9- to 17-year-old patients, their parents, and clinicians (psychologists, social workers and nurses) in an outpatient CAM unit.
Study I showed that routine questions identified many more IPV cases than expected from the known prevalence rate on the unit. Routine questions about IPV were difficult to implement, however.
In study II clinicians were interviewed about their difficulties in asking routine questions about IPV using a written questionnaire. Their responses showed that they were anxious about damaging their relationship with the parent, anxious about putting the mother in danger of recurrent IPV and self-critical about their performance in this area. The questionnaire facilitates gathering information through asking routine questions about IPV as a matter of routine, but its implementation requires management support and family intakes complemented by meetings in private.
Sammanfattning (Swedish summary)
Barnmisshandel uppmärksammades på samhällsnivå på 1960-talet och våld mot kvinnor lyftes som en viktig samhällsfråga av kvinnorörelsen på 1970-talet i Sverige och andra västländer. Forskning kring våld mot kvinnor har etablerats i en feministisk tradition och har senare kompletterats med ett könsneutralt paradigm – familjevåldsforskning. En diskussion om karaktären av partnervåld pågår mellan forskare hemmahörande i olika paradigmen.
I Sverige är det sedan 1979 inte tillåtet att slå sina barn i uppfostrande syfte. Det görs ingen skillnad mellan barnmisshandel och aga, vilket görs i många andra länder.
Det finns ganska god överensstämmelse bland forskare om vad som bör rymmas i en definition av partnervåld, men många aspekter av våldet är ändå svårfångade. Det innebär att rapportering om förekomst av partnervåld kan variera, beroende på metodmässiga aspekter av studierna. Det samma kan sägas om studier av barnmisshandel. När barn och ungdomar tillfrågas i Sverige visar det sig att ca vart tionde barn har blivit slaget hemma en enstaka gång och vart tjugonde barn har varit med om detta ett flertal gångar. Att ha bevittnat våld mellan föräldrar rapporteras av barn och ungdomar i samma omfattning som förekomst av direkt våld. Omkring hälften av barn som bevittnat våld mellan föräldrar har också blivit slagna.
Varför våld uppstår mellan vuxna i ett parförhållande finns det flera teoretiska förklaringar på. Feministisk teori förklarar mäns våld mot kvinnor utifrån ett könsmaktsperspektiv, där män upprätthåller makt och kontroll i intima relationer, liksom i övriga delar av samhällslivet. I den mån kvinnors våld mot män förekommer, anses den som väsensskild från manligt utövat våld. Individinriktade teorier hänför våldsutövande till psykologiska störningar (t.ex. personlighetstörningar) och sociala problem (t.ex. alkoholmissbruk eller fattigdom) som orsaksförklaring. Inom anknytningsteori menar man att en bristfällig anknytning under barndomen kan komma att påverka framtida intima relationer, och kan vara en riskfaktor för våldsutövande eller våldsutsatthet. Det finns ingen gemensam teoribildning som omfattar både partnervåld och barnmisshandel, men många av orsaksförklaringarna till partnervåld gäller också för barnmisshandel. Inom forskning på barnmisshandel används ofta den ekologisk transaktionella modellen som understryker att många samverkande faktorer i barns liv är bestämmande för om barnmisshandel förekommer.
och de efterföljande problemen finns flera teorier; exempelvis anknytningsteori, utvecklingspsykopatologi, social inlärningsteori och traumateori.
Inom vuxensjukvården vet man att kvinnor tycker det är acceptabelt att bli tillfrågade om de varit utsatta för partnervåld. Man vet också att professionella har svårt att ställa frågor rutinmässigt om partnervåld. Studier om svårigheter att fråga om partnervåld och barnmisshandel inom barnsjukvård är mycket få. Socialstyrelsen rekommenderar att man inom barn-och ungdomspsykiatrin (BUP) rutinmässigt frågar om våldsutsatthet. Därför debatteras i Sverige för närvarande etik och säkerhet samt frågor om hur man på bästa sätt tar upp frågan i patientmötet.
En del barn som utsatts för barnmisshandel och som bevittnat våld mellan föräldrar blir patienter inom BUP. I Sverige har en enstaka rapport dokumenterat att patienter som bevittnat våld mot sin mamma är ca 25 %. Hur barnpsykiatriska patienters erfarenheter av våld är kopplade till psykiska symptom finns det inga studier av i Sverige – och få internationellt.
Det övergripande syftet med studierna var, inom BUPs öppenvård, att (1) undersöka förekomsten av barnmisshandel och våld mellan föräldrar (2) undersöka behandlares inställning till att fråga rutinmässigt om våld (3) jämföra psykiatriska symtom mellan patienter som upplever familjevåld (utsätts direkt och/eller bevittnar våld mellan föräldrar), upplever våld utanför familjen eller inte varit utsatta för våld och (4) jämföra psykiatriska symptom mellan patienter som både utsätts för direkt våld och bevittnar våld med patienter som enbart utsätts för en av dessa våldstyper. Samstämmigheten mellan barns och föräldrars rapportering om partnervåld och betydelsen för barnens symtom studerades. Studierna i avhandlingen bygger på data insamlade från patienter i åldern nio till 17 år och deras föräldrar samt från behandlare (psykologer, socionomer och sjuksköterskor).
Studie I, som var explorativ, visade att en femtedel av mammorna till patienterna inom BUP hade utsatts för våld av sin nuvarande eller före detta partner. Studien visade också att rutinmässig kartläggning av partnervåld var svår att införa.
rutinmässig kartläggning var att det gav en tydlig information om våldsutsatthet och att behandlarna inte missade att fråga om våld.
I studie III fick 305 patienter svara skriftligt på om de upplevt familjevåld (utsatts direkt och/eller bevittnat våld mellan föräldrar). Nästan hälften av patienterna bekräftade detta. Patienternas svar visade att de som upplevt familjevåld i kombination med våld utanför familjen hade fler självrapporterade symtom generellt och fler kamratproblem jämfört med patienter som inte varit med om våld vare sig i eller utanför familjen. Patienter utsatta för våld både i och utanför familjen fick också oftare diagnosen posttraumatiskt stressyndrom (PTSD) jämfört med patienter som inte utsatts för våld. Patienter som upplevt våld både i och utanför familjen skattade upplevelserna av våld mest negativt, därefter kom de som enbart upplevt familjevåld och därpå de som endast upplevt våld utanför familjen.
I studie IV adderades fler patienter till det urval som ingick i studie III och totalt 578 patienter ingick därmed i studie IV. Patienter utsatta för direkt våld jämfördes med de som bevittnat våld mellan föräldrar och de som utsatts för både och (dubbelt utsatta). Patienter som hade utsatts direkt var 14 % och lika stor andel (14 %) hade bevittnat våld mellan föräldrar, medan 22 % var dubbelt utsatta. De dubbelt utsatta patienterna hade fler självskattade symtom generellt och fler beteendeproblem jämfört med patienter som utsatts för endast en typ av våld. De dubbelt utsatta patienterna hade också oftare PTSD-diagnos och skattade våldsupplevelserna mera negativt än de patienter som enbart utsatts direkt eller enbart bevittnat våld mellan föräldrar. Barn som bevittnat våld mellan föräldrar skiljde sig inte på symtomnivå från de som utsatts direkt för våld. Patienter som utsatts för endast en våldstyp skilde sig inte heller från övriga patienters (de som vare sig var utsatta för direkt våld eller bevittnat). När hänsyn togs till andra faktorer (t.ex. kön, ålder när man utsattes, frekvens av våldshändelserna och våld utanför familjen), visade sig antalet våldshändelser barnet utsatts för ha betydelse för den negativa inverkan. Dubbel utsatthet var den faktor som hade starkast samband med att barnet fått diagnosen PTSD. Samstämmigheten mellan barns och föräldrars rapportering om förekomst av partnervåld var god. Bland barn som var överens med föräldern om att partnervåld hade förekommit, var påverkan av våldsupplevelserna mera negativ. Där barn rapporterade partnervåld, men ej föräldern, hade barnen oftare en förstämnings-diagnos.
Acknowledgements
This thesis was made possible by Queen Silvia Children’s Hospital in Gothenburg, Sweden. I feel privileged, as one of only a few from an outpatient unit at our clinic, to have the opportunity to do clinical research in child and adolescent psychiatry.
The data for the studies were collected by my colleagues from the Child and Adolescent Psychiatric Outpatient Unit in Gamlestaden, Gothenburg. As the studies in this thesis were part of a treatment study, children and parents spent a considerable amount of time answering questions. Informants in the studies were mainly children, adolescents, and parents attending the clinic. I would like to express my gratitude to the therapist colleagues who interviewed the patients, the secretaries who did all of the necessary paperwork, and the families who contributed their experiences. Both researching and intervening in family violence are difficult matters to handle. From my contact with the children and parents, I know that most of them appreciated their contact with the therapists and were glad to contribute to the research project.
Two people were essential to making the studies reported here possible and carried me through the project. One of them laid out the master plan; the other made it possible to conduct the research in an ordinary clinic.
My supervisor, Professor Anders Broberg, supported me all through this project. Our budgeted two-hour supervision meetings during my years as a PhD student were not enough, I can assure you, and Anders was very generous with extra time. Anders’ background as a clinical psychologist and psychotherapist makes him excellent for doing clinical research and particularly qualified to supervise such research projects. His energy seems endless, and his patience and supportive approach contributed greatly to my ability to research and write this thesis.
Marie Hellsten, on-site manager where the studies took place, is also a psychotherapist. Without her skills and advice about how to handle difficult processes in the work groups, we would never have made it. To help a group of psychologists and social workers engage co-operatively in a research project is a challenge. Marie made it work by directing her employees to follow their inclinations to do what they were best suited to. She also managed all the operational structures in order to take care of her employees during the process.
Child psychiatrist Björn Magnér was supportive and enthusiastic during the entire project. Associate Professor Tord Ivarsson devoted time to teach the noble art of assessment according to the Diagnostic Statistical Manual of Mental Disorders. Thanks also to Anna Zackrisson-Toller for essential administrative support at the start of the project and to Annlie Holm-Möller for her help at the end of the project. I would also like to thank secretary Jaana Wadstedt for making economic matters work smoothly and Professor Staffan Janson for valuable comments on the draft.
I owe a big thank you to all the students who chose to write their master’s thesis on our data: Andrea Valik, Rebecca Fihnn, Amanda Sondefors Tiedje, Carl Nilsson, Jonas Bretan, Elin Bergman, Maria Davidsson, and Emma Svensson. Cerisa Obern, thank you for helping me on the way to mastering written English. The language support from university of Gothenburg delivered by Jenny Mattsson has been excellent. Dr. Karin Grip and my colleague Hedvig Kalén helped me to do some crucial thinking about presenting the results, and I thank psychology student Puya Yekerusta for typing in endless strings of data. Finally, I am grateful for the support from my co-supervisor, senior lecturer Ulf Axberg.
Two networks have been of great importance during my time as a PhD student. The Network on Violence and Gender in Gothenburg initiated by Dr. Viveka Enander has been a pleasure to take part in. An important academic context has been the Nordic Network for Abused Children organized by Professor Maria Eriksson from Mälardalens högskola.
I would especially like to thank the woman in my life, Britta Pettersson. Your realistic time planning helped me to get finished in time. Your encouragement and language skills have been very supportive.
Main sponsors of the research projects were The Mayflower Foundation, The Children’s Welfare Foundation, The Swedish Crime Victims Compensation Fund and Support Authority, The Swedish Research Council for Health, Working Life and Welfare.
Publications
This dissertation is based on the following four articles, referred to in the text by their Roman numerals, which describe a related series of studies:
I. Hedtjärn, G. I., Hultmann, O., Broberg, A. G. (2009). One out of five mothers of children in psychiatric care has experienced domestic violence. Läkartidningen, 106 (48), 3242-3247 [Originally published in Swedish: Var femte mamma till barn i BUP-vård hade utsatts för våld: Mörkertalet kan vara stort, visar explorativ pilotstudie].
II. Hultmann, O., Möller, J., Ormhaug, S. M. & Broberg, A. G. (2014) Asking Routinely About Intimate Partner Violence in a Child and Adolescent Psychiatric Clinic: A Qualitative Study. Journal of Family Violence. 29, 67-78. doi: 10.1007/s10896-013-9554-5
III. Hultmann, O. & Broberg, A. G. (2015) Family Violence and Other Potentially Traumatic Interpersonal Events Among 9- to 17-Year-Old Children Attending an Outpatient Psychiatric Clinic. E-pub ahead of print in Journal of Interpersonal Violence. doi:
10.1177/0886260515584335
Content
Preface ... 1
INTRODUCTION ... 3
A brief history of family violence research ... 3
Definitions and core concepts in the realm of child abuse and IPV ... 6
IPV ... 6
Child abuse ... 8
Definitions in CAM ... 9
Definition of double exposure ... 9
Aggression ... 9
Prevalence of child abuse and IPV ... 10
IPV ... 10
Child abuse ... 11
Prevalence of double exposure ... 12
Etiology of perpetration and victimization to child abuse and IPV ... 13
IPV ... 13
Feminist theory ... 13
Interpersonal theories ... 14
Individual focused models ... 16
Child abuse ... 18
Etiology of double exposure ... 20
Consequences of child abuse and IPV on child development and psychopathology ... 20
Theoretical aspects ... 20
Developmental psychopathology... 20
Attachment theory ... 21
Social learning theory. ... 23
Trauma theory ... 23
Social adjustment ... 25
Psychopathology ... 25
IPV ... 25
Child abuse ... 26
Unique and cumulative effects of child abuse, IPV, and other traumatic events ... 27
Moderating factors ... 30 Dose-response ... 30 Parental functioning ... 31 Child factors ... 31 Gender. ... 31 Age ... 32
Disclosure of child abuse and IPV ... 32
Ethical considerations ... 33
Informant ... 35
Summary ... 38
THE CURRENT STUDIES ... 43
Aims of the thesis ... 43
Study I ... 43 Aims ... 43 Methods ... 43 Results ... 44 Discussion ... 44 Study II ... 45 Aims ... 45 Methods ... 45 Results ... 45 Discussion ... 46
Studies III & IV ... 46
Aims ... 46 Study III ... 46 Study IV ... 47 Methods ... 47 Study III ... 47 Study IV ... 47 Results ... 48 Study III ... 48 Study IV ... 48 Discussion ... 51 Study III ... 51 Study IV ... 51
Summary of the four studies ... 52
GENERAL DISCUSSION ... 55
Strengths and limitations ... 60
Clinical conclusions ... 61
References ... 62
RESEARCH PAPERS ... 75
Preface
The more details one comes to know about the events in a child’s life, and about what he has been told, what he has overheard, and what he has observed but is not supposed to know, the more clearly can his ideas about the world and what may happen in the future be seen as perfectly reasonably constructions (Bowlby, 1979, p. 23).
During data collection for the studies in this thesis, clinicians asked hundreds of patients about their experiences of violence. After the intake procedures at the clinic, some of the children were asked how they felt about answering questions about violence. One adolescent said it was “annoying, but still ok. So you can stop the violence.” Another said, “Good. It feels like all my problems come from these experiences.” In my 25 years as a clinical psychologist in child and adolescent mental health care (CAM), I have found the connection made in the clinical world between children’s negative life experiences (violence) and psychiatric symptoms to be quite weak. Although well-known as a public health problem, family violence has not been approached in a systematic way in CAM.
In 2005, the Department of Psychology, Gothenburg University, Sweden sent a request to our CAM unit. A need for specialized treatment had emerged during a research project examining support groups for children exposed to family violence. Some children who attended the groups did not improve and needed interventions for their psychiatric symptoms after finishing their group sessions. Fortunately, at the CAM unit we had familiarized ourselves in the 1990s with trauma work and how to help trauma victims. Our work with refugees (Norblad, 2014) and the survivors of a discotheque fire in Gothenburg (Broberg, Dyregrov, & Lilled, 2005) had made us familiar with traumas that originate outside the family. Traumas from within the family were, however, still a more or less uncharted territory for us. Therefore, we asked a psychology student to carry out focus group interviews with the clinicians regarding the current status of our work, particularly with regard to children affected by family violence (Onsjö & Broberg, 2007). The interviews made it clear that we lacked the necessary methods to detect such violence and most of our interventions were brief crisis interventions, rarely more comprehensive or focused psychotherapeutic interventions. The interviews also showed that we had no idea how many of our patients were affected by family violence, and we did not know how precisely to define the phenomenon.
the first data collection by routinely asking mothers at the intake interview if they had been subjected to IPV. This required changes in the clinicians’ intake routines, which were not easily made. Focusing on violence also imposed an emotional burden on the clinicians, and the children’s and parents’ safety became an urgent issue. As new treatment methods were introduced, professionals’ involvement in helping children affected by violence increased.
After 10 years of intense work with children exposed to family violence, much has changed at the unit. Family intakes are now complemented by private interviews with both the parents and the children. When routine questions indicate exposure to violence a thorough risk and safety assessment is conducted (Broberg et al., 2015). Patients are offered trauma treatment such as trauma-focused cognitive behavioral therapy (TF-CBT).
The thesis opens with an exposition of definitions and the prevalence of child abuse and IPV, followed by an overview of relevant theories on the etiology of perpetration and victimization in child abuse and IPV and on symptoms in subjected and exposed children. The consequences of child abuse and exposure to IPV are then described and finally the ethical and practical problems associated with disclosure of abuse and IPV are reviewed.
Introduction
A brief history of family violence research
Public awareness about child abuse and family violence was raised in the late part of the 20th century. The United Nations (UN) has declared violence against women a global public health problem, and The World Health Organization (WHO) has declared child abuse a subject of crucial interest for public health. In Sweden, the government recently passed a gender equality policy with the specific goal of abolishing men’s violence against women (SOU, 2015:55). Government action is a crucial step in fighting child abuse and family violence; however, each nation’s dedication and practice to this cause varies. A short modern history of the academic disciplines focusing on family violence follows.
Violence against women. Women’s movement protests against the structural problems of the suppression of women in general and of violence against women in particular first brought family violence into public awareness. In the early 1970s, women in the USA started “consciousness-raising” groups to discuss relevant life issues (McCue, 2008). On the other side of the Atlantic, in Great Britain, women organized a march for free milk for school children, which eventually led to the establishment of the first women’s shelter, The Battered Wives’ Centre, in Chiswick. Since then, the women’s movement to end wife-beating spread to many other countries, and women’s shelters often became a part of government-funded programs. The academic discipline of feminism developed out of the initial work of the women’s movement.
Feminist researchers assert that the context in which violence is perpetrated must be taken into account; the intentions and consequences of violent behavior must be measured as well as the violent acts. This is the structural paradigm.
The individualistic perspective. This perspective is often called the family violence perspective, and this term will be used here. The family violence perspective emerged in the 1980s (Straus, 2011). Family violence scholars use the same standards to measure male and female perpetrated violence. They do so on the basis of violent actions per se and pursue a perspective of gender symmetry (Winstok, 2011). Contrary to feminist scholars, family violence scholars hold the view that IPV is symmetrical, i.e. that gender is not the primary significant factor in predicting IPV. Family violence is studied from a paradigm of conflict between partners. The causes of violence remain in the individuals perpetrating it. Violent acts are studied as behavioral units, without regard for the contexts in which they are perpetrated.
As a compromise between these two distinct perspectives, scholars have suggested that different types of family violence exist. One suggestion is that one must differentiate between severe violence and ordinary violence. Men are considered more likely to be perpetrators of severe violence, and “ordinary” violence is thought to be perpetrated more symmetrically (Johnson, 2006). Kelly and Johnson suggest four patterns:
1. Coercive controlling violence includes intimidation, emotional abuse, isolation, minimizing, denying and blaming, use of children, asserting male privilege, economic abuse, and coercion and threats. Coercive controlling violence is often found in settings such as courts, women’s shelters, and hospitals, and is primarily perpetrated by men.
2. Violent resistance includes self-defense, usually by women defending themselves against violent attacks by men.
3. Situational couple violence occurs between partners with poor anger management who engage in mutual minor forms of violence.
4. Separation-instigated violence can be perpetrated by either partner in the separation process, most often the partner who is being left (Kelly & Johnson, 2008).
Larsen, 2015). Studies show that woman-perpetrated physical violence against a partner usually occurs in response to the man’s violence. They also show that women are more fearful than men and more often injured.
Child abuse. As in the case of violence against women, it was a women-driven social movement that brought child abuse onto the public agenda back in the late 19th century (Myers, 2010). Jane Adams was a central figure in the settlement movement working for child protection. Pediatricians began focusing on child abuse in the 1960s; however, a radiologist, John Caffey, wrote a scientific article about the issue as early as 1946. Henry Kempe and colleagues later drew attention to abused children with their article “The Battered-Child Syndrome” in 1962 (Myers, 2010). Due in part to Kempe’s work, the reporting of suspected child abuse in the USA dramatically increased from 60,000 reports in 1974 to three million reports in 2000. Public interest in the topic of sexually abused children also increased in the 1970s, particularly after V. De Francis’ study in 1969 about 250 sexually abused children and the subsequent emotional damage they suffered (Myers, 2010).
In Sweden in the 1960s, pediatricians, social workers and child advocates (lawyers), and the Swedish National Board of Health and Welfare (NBHW) also started to recognize violence against children as a problem (Janson, Jernbro, & Långberg, 2011). Since 1998 it has been illegal to affront women, children, and other close relatives (Brottsbalken, 1962). If offensive acts are repeated in order to affront another’s integrity and harm their self-confidence, perpetrators may be convicted.
Corporal punishment. Parenting practices, child rearing, and care-giving differ between countries (Krug, Dahlberg, Mercy, Zwi, & Lozano, 2002). A survey in Brazil, Chile, Egypt, India, the Philippines, and the USA showed that spanking ranged from 15% in highly educated groups to 76% in lowly educated groups (Runyan et al., 2010). In Sweden, authoritarian parenting (parenting by fear) has by and large been abolished and a similar trend holds in the other Nordic countries (Janson et al., 2011). The Parental Code [Föräldrabalken] was passed in Sweden’s parliament in 1979, and since 1982 it has been a crime to abuse or punish a child by corporal means (Brottsbalken, 1962). Corporal punishment is still legal in most countries around the world, but none of the Nordic countries (Sweden, Norway, Denmark, Iceland, and Finland) permit it (Rädda Barnen, 2015).
outside Sweden. In particular, boys born abroad are at high risk of corporal punishment. Other social factors that worsen these harsh parenting practices in immigrant families are lower education, higher unemployment, and a lower standard of housing (Janson et al., 2011).
Definitions and core concepts in the realm of child abuse and IPV
Political and cultural context and common use of the concepts of child abuse and IPV shape our understanding of the phenomena. Clear definitions of terms are crucial to building consistent concepts for studying and communicating about child abuse and IPV. Which actions should be considered child abuse or IPV, and which should not? In this thesis, child abuse is seen as a specific type of harmful acts by caregivers that can be differentiated from other types of harm to children. This concept of child abuse encompasses the several sub-categories described below. Violence between intimate partners can also include a few or many types of actions. The specific dimensions of a child-centered perspective on IPV will also be described.
IPV
In this thesis, the term IPV is restricted to violence between intimate partners but incorporates several perspectives. It includes violence perpetrated by and against both women and men, while also recognizing gender-based power- and control-driven violence against women. Different terms and concepts are used within the field of violence between intimate partners, and some of them will be described here.
Because violence against women is an influential perspective in research and government-initiated actions, it is important to mention the UN’s official definition of the term as:
… any act of gender-based violence that results in, or is likely to result in, physical, sexual or psychological harm or suffering to women, including threats of such acts, coercion or arbitrary deprivation of liberty, whether occurring in public or in private life (Article 1; United Nations, 1993).
This definition of violence against women includes actions in public life including female genital mutilation, rape, non-spousal exploitation, prostitution, and violence condoned by the state (United Nations, 1993).
The academic literature uses different concepts about violence against women, such as wife abuse, woman abuse, and woman battering, and in these terms the gender of the person abused is spelled out. One of the first terms used by the feminist movement in the 1980s was domestic violence (Enander, 2008). This term is gender-neutral and may also include also violence against children (Walsh et al., 2015) parents, elders, and siblings (Robinsson, 2014). It is no longer used by feminist researchers because of its gender neutrality and because it refers to a place rather than a person (Enander, 2008). IPV is a term widely used by such bodies as WHO to discuss violent acts between intimate partners (World Health Organization, 2013). The term family violence is used with the same implications as domestic violence. All three concepts include violence perpetrated by either partner and the concepts are gender-neutral. The term family violence scholars is used to denote researchers who study IPV as a mutual phenomenon in contrast to feminist researchers who study violence against women (Winstok, 2011).
According to the U.S. Centers for Disease Control and Prevention (CDC), IPV “includes physical violence, sexual violence, stalking and psychological aggression (including coercive tactics) by a current or former intimate partner (i.e., spouse, boyfriend/girlfriend, dating partner, or ongoing sexual partner)” (Breiding, Basile, Smith, Black, & Mahendra, 2015, p. 11).
In Sweden, the concept of violence in close relationships [våld i nära relationer] is widely used (Nationellt centrum för kvinnofrid, 2015) and includes, along with child abuse and IPV, violence between siblings, close family members, and other relatives.
Psychological abuse1. The terms psychological abuse and emotional abuse are used
interchangeably in the academic literature. Psychological abuse is a pattern of aggressive acts, verbal or non-verbal, intended to harm another person mentally or emotionally and/or to exert control over that person (Breiding et al., 2015). Feminist researchers have long highlighted this psychological component of IPV as a tactic used by men to exert power and control over women (Enander, 2008). Psychological abuse generates fear and anxiety, removes social support, impoverishes, and undermines self-esteem (Jewkes, 2010). Defining and measuring psychological abuse is a serious challenge for researchers. Because it mostly co-occurs with physical or sexual violence and can take many different forms, it is often overlooked (Jewkes).
1In the latest CDC terminology the concept psychological aggression replaces the concept psychological abuse from earlier version of these
Children and IPV. When the partners are parents, the child’s perspective on IPV must be taken into consideration. Children can be in the position of witnessing violence, but often they will be more than just witnesses when they overhear, taking part in, or watch the aftermath of IPV. An alternative concept proposed, but not widely used, is participating witness (Hydén, 1995). Some researchers use the concept experiencing violence, which is quite similar to exposed to violence. Yet another suggested term is children forced to live with IPV, which stresses children’s lack of free will to avoid the violence (Goddard & Bedi, 2010).
Children can be involved in IPV in many ways: being eyewitnesses to or overhearing violent acts, being victimized themselves during an incident, intervening in the violent situation, taking part in perpetration, or being exposed prenatally (Holden, 2003). Children can also see the effects (e.g. bruises, damaged property). Violence between parents can be physical or emotional and the perpetrator’s personality can range from normal to severely disordered. Victims can be frightened and upset or in control of their reactions. Perpetrator and victim characteristics and reactions influence the child’s perception of threat.
Child abuse
The definition of child abuse includes both acts and threats of physical violence, sexual violence, and psychological violence (Leeb, Paulozzi, Melanson, Simon, & Arias, 2008). “Physical abuse is defined as the intentional use of physical force against a child that results in, or has the potential to result in physical injury” (Leeb et al., 2008, p. 14). Child sexual abuse is “[a]ny completed or attempted (non-completed) sexual act, sexual contact with, or exploitation (i.e. noncontact sexual interaction) of a child by a caregiver” (Leeb et al., 2008, p. 14). Psychological abuse is “[i]ntentional caregiver behaviour (i.e., act of commission) that conveys to a child that he/she is worthless, flawed, unloved, unwanted, endangered, or valued only in meeting another’s needs” (Leeb et al., 2008, pp. 14-16).
Definitions in CAM
In Diagnostic and Statistical Manual of Mental Disorders (DSM-5) physical, sexual, and psychological abuse are listed as V-codes for child maltreatment as well as for spouse/partner violence, that may be focus of clinical attention or which could otherwise affect the patient’s diagnosis, course, prognosis, or treatment (American Psychiatric Association, 2013). Operational definitions of actions qualifying as child abuse are listed. Each category of abuse has a conceptual definition, and examples of a threshold for distinguishing suboptimal care-giving from abuse are presented. V-codes are listed for physical, psychological, and sexual spouse/partner violence as well, constructed in the same way as the child maltreatment codes. The impact of IPV is mentioned as part of the definition, but is not operationally defined.
Definition of double exposure
When both abuse and IPV are present in the same family, it is known as co-occurrence. Other terms used are intersection, or double exposure. According to WHO researchers, these concepts are not rigorously defined in the academic literature and, thus, need clarification (Guedes & Mikton, 2013). Child abuse and IPV may occur at varying times, and one type of violence may be a risk factor for the other. Furthermore, one or both parents may perform child abuse and/or IPV. These two types of violence can occur in the same family in a variety of ways, as proposed by Appel and Holden: (1) a single perpetrator of child abuse and IPV, (2) the victim of IPV abuses the child, (3) both victim and perpetrator of IPV abuse the child, (4) mutual IPV and abuse of the child by one or by both parents, and (5) both parents and child engage in violent acts against each other (Appel & Holden, 1998).
The term exposure is used consistently in this thesis; therefore, double exposure will also be used to refer to the occurrence of both child abuse and exposure to IPV.
Studies of child abuse and IPV may not be conducted in line with the clear-cut definitions presented above. Measurement dimensions (e.g. past-year vs. lifetime, whether emotional and sexual abuse is included, whether both victimization and perpetration are included, and whether children themselves or one or both parents are informants) will vary between studies. Measuring the magnitude of child abuse and IPV is relevant for both researchers and policy makers. Prevalence figures inform society about, for example, whether and how to initiate preventive measures and evaluate interventions.
Aggression
may explain violence in the family in some cases, aggression also has other functions and purposes.
Aggression is “any form of behavior that is intended to injure someone physically or psychologically” (Berkowitz, 1993, p. 3). The goal of aggression can be to influence another person’s behavior (coercion) or to impress other people by showing strength, competence, and courage. The goal can also be to exert power and dominance. Aggression can be emotionally driven by the pleasure of hurting other people or used rationally to achieve something such as money, territory, or safety (instrumental aggression). All of these types of aggressive behavior can be either consciously controlled or more driven by impulsive. A concept related to aggression is the feeling of anger, which does not imply action and does not have a specific goal to injure. Hostility is an attitude of ill-will and aggressiveness is the persistent readiness to become aggressive (Berkowitz, 1993). Violence is aggressive behavior, and clearly also rule-breaking behavior. Thus all violent acts can be considered aggressive, but not all aggression is violence. Violence will by definition cause harm.
Prevalence of child abuse and IPV
Rates of IPV are calculated as either past-year prevalence or lifetime prevalence. It is common to include physical, psychological, and sexual violence in the definition. Rates of child abuse are mostly calculated as lifetime prevalence. Studies usually either count rates of maltreatment (including physical, psychological, and sexual abuse, as well as neglect) or of physical abuse only.
IPV
Worldwide each year 133 to 275 million children witness violence between their parents
(Pinheiro, 2006). United Nations Children's Fund estimates from their global databases that
almost half of adolescent girls worldwide think it is acceptable for a man to punish his wife physically under certain circumstances (United Nations Children´s Fund, 2014). The prevalence of IPV in the general population is lower in Nordic countries than in other high-income countries in Europe and North America (Gilbert et al., 2009).
associated with exposure to violence. A report from the Swedish National Council for Crime Prevention estimated the prevalence of violence in close relationships, including systematic assaults and humiliations, restriction (of the partner’s right to freedom), threats, harassment, and physical and sexual abuse (Frenzel, 2014). This national survey showed similar past-year prevalence of male and female victimization (7%) and a higher lifetime prevalence for women (26%) than for men (17%). Lifetime prevalence for violence was higher for women than for men, they were more often subjected to recurrent physical violence, the effects on them tended to be more serious, and they were more likely to be injured. Single mothers were most likely to be affected by violence in close relationships.
Swedish studies in children. In Sweden, the estimated lifetime prevalence of exposure to IPV is 10% for a single exposure and 5% for repeated exposure (SOU, 2001:72) in the general population. When asked directly, 13% of adolescents reported a single exposure to IPV and 4% reported multiple exposures (Annerbäck, Wingren, Svedin, & Gustafsson, 2010). How the IPV question was phrased was not reported. In a Swedish classroom study on teenagers, 12% reported that they had witnessed one family member being beaten or wounded by another (Nilsson, Gustafsson, & Svedin, 2012). The pupils completed the Lifetime Incidence of Traumatic Events (LITE) questionnaire. IPV was screened in by the item “parents (or grown-ups) broke things or hurt each other.” In another Swedish study among 15- to 16-year-olds, 6% of adolescents reported exposure to IPV a single time and 2% reported multiple times (Janson et al., 2011). How the IPV question was phrased was not reported.
CAM studies. The prevalence of IPV in general CAM populations has been documented in only a few studies. In Spain, a past-year exposure rate of 20% was reported (Olaya, Ezpeleta, de la Osa, Granero, & Doménech, 2010). Other studies that did not restrict prevalence to a specific time frame included USA: 20% (Ford, Gagnon, Connor, & Pearson, 2011a), Finland: 25% (family violence) (Ryynänen, Alen, Koivumaa-Honkanen, Joskitt, & Ebeling, 2015), and Norway: 39% (Ormhaug, Jensen, Hukkelberg, Holt, & Egeland, 2012). Prevalence of IPV was reported to be 43% and 47% among CAM patients with behavioral problems in other studies in the USA (McDonald, Jouriles, Norwood, Shinn, & Ezell, 2000; Stewart, deBlois, Meardon, & Cummings, 1980).
Child abuse
Baltic countries and Russia, child abuse is even more frequent. In Sweden, less than 10 children die as consequence of abuse each year (Socialstyrelsen, 2011). In other Scandinavian countries and Southern Europe, the prevalence of death for children who die from child maltreatment is low, while in other countries (e.g., the USA and central and eastern Europe) the numbers are much higher (Gilbert et al., 2009).
A recent study of physical abuse in the USA for children aged 0- to 9-years-old (parent reports) and youth aged 10 to 17 (self-reports) indicated a 9% lifetime prevalence. Multiple incidents (more than 11 times) were reported by 45% of the informants (Finkelhor, Vanderminden, Turner, Hamby, & Shattuck, 2014a). The overall response rate was low and the study may have scored the prevalence rates too low according to the authors. In Sweden, 15-year-olds’ self-reported prevalence of a single incident of physical abuse was 14% and for repeated incidents it was 3% (Janson et al., 2011). In another Swedish study, 16% of adolescents reported physical violence from parents and 7% reported repeated incidents (Annerbäck, Sahlqvist, Svedin, Wingren, & Gustafsson, 2012).
Very few studies on prevalence of child abuse in CAM have been conducted. In a study of boys with hyperactivity and conduct disorders, with parents as informants, the prevalence of physical abuse was 32% (Stewart, deBlois, & Cummings, 1980). In a study in Norway the reported prevalence of abuse for children and adolescents aged 10 to 18 years was 39% (Ormhaug et al., 2012). In the third study, CAM patients 7 to 9 years old with conduct problems were physically abused an average of 10 to 14 times a year (Jouriles, Mehta, McDonald, & Francis, 1997).
Prevalence of double exposure
their mother showed that 62% of the children had been abused physically or emotionally by their father or stepfather (Almqvist & Broberg, 2004). Of the 41 children who had been abused, 11 reported severe and repeated abuse.
Etiology of perpetration and victimization to child abuse and IPV
Violence is multi-determined by a variety of factors inherent in the adult perpetrators and victims and in their social situation. Currently, there are no theoretical models describing the common ground between child abuse and IPV, but many etiological factors for child abuse are also those of IPV. When analyzing the determinants of IPV it is important to remember the model of gender-based power- and control-driven violence, although, the possible cultural and political structures behind this kind of violence will not be addressed here. Feminist, individual, and interpersonal theories are, however, all of interest and will be described.
When violence-affected children receive interventions in CAM, the roles of the parents must always be taken into consideration. Therapeutic interventions, including parental participation, presume that violence against the child has ended. Explanations of the causes and dynamics of child abuse and IPV are relevant for clinicians aiming to introduce helpful interventions.
IPV
Feminist theory
According to the feminist paradigm introduced by Pence and Paymar, men perpetrate violence against women in order to exercise power and control over them (1993). Structural factors prevent women from gaining equality and participation in social, economic, and political systems. These structures are reproduced in the family where the man is in charge, and boys and girls learn to reproduce gender roles. Understanding violence against women using a structural theory denies that violence can be reduced to the effects of the man’s individual psychological disturbance (Walby, 1990). The theory rejects the idea that men who batter are deviant in terms of psychopathology. Instead, all men are held to be capable of beating their intimate partner if their position of power is threatened (Walby, 1990). In this view, therefore, violent relationships are not radically different from “normal” intimate relationships. If a man does not have clear economic and educational superiority over his wife, he is more likely to use physical violence against her (Walby, 1990).
quite common and includes a variety of psychological violations to control the woman. Sexism and “harmless” affronts to the woman’s integrity are noted as part of the continuum of violence or sexualized violence. Other feminist researchers focus on different tactics of emotional abuse (Enander, 2008). If these mechanisms of control are effective, physical violence may not be necessary in the eyes of the controller.
IPV is basically an asymmetrical phenomenon. In the feminist paradigm, male perpetrated violence must be understood as a phenomenon separate from violence perpetrated by women against men. Although woman perpetrated violence may occur, it does so in the context of male perpetrated violence, i.e. as a defensive violence sometimes enacted in a state of fear.
Interpersonal theories
Attachment needs are innate and serve to create a child’s emotional bonds to its caregivers. Infants learn to use caregivers as secure bases from which to explore the world and as safe havens to return to when the attachment system is activated by a real or perceived threat. “The basic goals of an attachment bond are to obtain security and comfort through the emotional availability and responsiveness of an attachment figure” (Schneider & Brimhall, 2014, p. 368). The attachment relationships between children and parents are thus asymmetric; the child is attached to and dependent on the parent. Romantic relationships in adulthood can also develop into attachment relationships. To function well, however, they should be reciprocal— both partners perceive the other as one who will offer protection and support in times of pressure or stress.
According to Bowlby, experiences of close relationships during childhood influence adult relationships through the developing child’s internal working models of self and others (Henderson, Bartholomew, Trinke, & Kwong, 2005). Children will generalize their experiences of protection, comfort, etc, with their caregivers to their expectations other people in close relationships.
conceited, feeling of self-worth, and a correspondingly high regard of others as potential sources of comfort when needed.
Attachment theory offers an explanation of how IPV can be transmitted from one generation to the next through the internal working models of attachment that each partner in an adult relationship brings with them. It is the interaction between these internal working models that will determine possible IPV, if the attachment needs of one individual are rejected by the partner. Attachment insecurity in both partners can make either one, or both, become violent against the other. The interaction of both partners’ attachment styles will determine whether aggression will occur (Bartholomew & Allison, 2006).
The most unlikely partners to conduct IPV are those with secure attachment, who feel worthy of being loved (low on the anxiety dimension) and perceive others as supportive (low on the avoidance dimension) (Bartholomew & Allison, 2006). Low self-esteem (high anxiety) and an excessive need of approval of others (low avoidance) will lead to hypersensitivity to cues of being left out or rejected. Such an attachment style is called pre-occupied or hyperactivating (of the attachment system). For people with this attachment style, feeling rejected leads to anger. If the partner does not offer comfort or support in such times of stress, but instead tries to avoid contact, that anger may turn into aggression. IPV can thus be regarded as a kind of protest behavior, also seen in children whose attachment needs are not met. Perceived threats of abandonment, separation, or rejection are the main triggers of IPV. If one partner is low on anxiety, downplays the importance of intimate relationships, and at the same time has a high or even inflated self-esteem, the attachment orientation is denoted dismissive or deactivating (of the attachment system). When this person’s partner demands closeness or is “overly” needy the person with a dismissive attachment style will perceive this as a threat, and may use physical force in self–defense (from intimacy). Adults with this attachment style tend to use IPV to maintain distance their partner in times of stress and conflict (Allison et al., 2008).
The fourth attachment orientation is fearful and is seen a person who ranks high on both the anxious and avoidance dimensions and avoids intimacy due to fear of rejection (Henderson et al., 2005).
Particularly high-risk dyads are those in which one partner is dependent on and seeks intimacy (preoccupied) and the other is dismissive and avoids intimacy.
criticism and blaming in the preoccupied attachment style will make the person’s partner reluctant to comfort or give support. Adults with preoccupied or fearful attachment styles are more likely both to perpetrate and to be recipients of IPV (Schneider & Brimhall, 2014). The dismissive attachment style has also been linked to men’s perpetration of IPV (Babcock, Jacobson, Gottman, & Yerington, 2000). Some insecurely attached adults, however, will not be more prone to engage in IPV, probably because they are totally disengaged in times of stress or conflict (Babcock et al., 2000).
Individual focused models
Individual models locate the origins of IPV in the perpetrator’s or victim’s psychopathology. The most relevant (DSM-5) types of psychopathology are Personality Disorders, Trauma and Stressor-Related Disorders, Disruptive, Impulse Control and Conduct Disorders, Substance-Related and Addictive Disorders, and Depressive Disorders (American Psychiatric Association, 2013). These can be related to the perpetration of IPV or may develop as a consequence of the partner’s victimization.
Approximately 15% of adults in the USA suffer from at least one personality disorder2.
Some of these disorders (e.g. antisocial personality disorder) are more frequent among males (American Psychiatric Association, 2013). Higher rates of personality disorders have been found among men in IPV treatment than in the general population (Dutton, Saunders, Starzomski, & Bartholomew, 1994). In a Norwegian study of men voluntarily in treatment, 20% fulfilled the criteria for a diagnosis of an antisocial personality disorder (Askeland & Heir, 2014). A review article also found that perpetration of IPV is more prevalent among males with personality disorders, especially borderline personality disorder, than in the general population (Ali & Naylor, 2013).
Posttraumatic stress disorder. People with a diagnosis of PTSD may show symptoms similar to symptoms of personality disorders: deviations in cognitions, affectivity, interpersonal functioning, and impulse control (the core criteria in personality disorders) (American Psychiatric Association, 2013). However, unlike personality disorders, PTSD symptoms are stress-related and associated with one or several previously experienced life-threatening traumatic events. Although the symptoms and subsequent violent behavior associated with these two diagnoses can be quite similar, the mechanisms inducing them are different.
2 A personality disorder is an enduring pattern of inner experience and behavior that deviates markedly from the expectations of
PTSD is associated with perpetration of IPV, especially by men and when the trauma is severe (Taft, Watkins, Stafford, Street, & Monson, 2011). One epidemiologic study found that the risk of perpetrating IPV was higher for men with PTSD, even when controlling for depression and substance abuse (Hahn, Aldarondo, Silverman, McCormick, & Koenen, 2015). Among females, IPV contributes to, rather than is caused by, the development of PTSD (and other psychiatric disorders, e.g. depression and drug abuse) as shown in a longitudinal study (Ehrensaft , Moffitt , & Caspi 2006).
Other psychiatric problems. Problems with emotional and behavioral regulation are listed in DSM-5 under the headline “Disruptive, impulse-control, and conduct disorders” (American Psychiatric Association, 2013, p. 461). These syndromes are not personality disorders, thus they are possibly easier to change, through psychotherapy, for example. Several longitudinal prospective studies have shown that conduct disorders or early behavior problems predict perpetration of IPV (Ehrensaft et al., 2003). Depression and anxiety disorders have also been found among men voluntarily admitted to treatment for IPV perpetration (Askeland & Heir, 2014).
Temperament. Individuals without a psychiatric diagnosis, but who score high on the temperament trait of negative emotionality, are also at risk for engaging in IPV (Moffitt,
Robins, & Caspi, 2001)3. A prospective study among young adults found that perpetrators of
general crime had lower self-control than perpetrators of IPV. Negative emotionality (e.g. poor coping, suspiciousness) was present in both groups (Moffitt, Krueger, Caspi, & Fagan, 2000). Interestingly, all findings applied to both men and women.
Studies have been conducted on perpetrators of IPV who have a hostile attitude or strong feelings of anger (Ali & Naylor, 2013). These persistent attitudes and feelings seem to be a contributing factor to the perpetration of IPV, but findings are inconsistent and the concepts need to be more precisely defined.
Alcohol abuse. Alcohol abuse is associated with IPV according to a meta-study by Foran and O´Leary (2008). In studies of male alcoholics the prevalence of partner violence is 50% to 60% compared to 12% in the general population. In studies on aggressive perpetrators, alcohol use was as high as 72% versus 24% in community samples.
Among prisoners incarcerated for murder, manslaughter, or assaults, common social characteristics were found regardless of whether the crimes were aimed at their partner or at someone else. They were alike on the dimensions of drinking at the time of the incident,
having alcohol problems, having a criminal record, having been abused by non-partners, and having been abused as a child (Felson & Lane, 2010).
In a study of males in a treatment program for IPV perpetrators, 40% of the sample fulfilled the criteria for an alcohol or substance abuse disorder (Askeland & Heir, 2014). In a Swedish national survey of 219 IPV-affected mothers, a third reported their partner abused alcohol and a fifth reported that their partner was a “problem drinker”. The sample was drawn from women’s shelters, CAM, and social services (Broberg et al., 2011).
For victims, use or misuse of alcohol is mainly a consequence, rather than a cause, of IPV according to several studies (Foran & O'Leary, 2008). The causal links between IPV and alcohol/drug abuse still need to be clarified (Ali & Naylor, 2013). The studies on psychiatric disorders and alcohol/drug abuse in relation to IPV perpetration and victimization referred to above, apart from that by Broberg et al., do not include CAM samples. A variety of more or less serious psychiatric disorders than those found in the studies reported above would probably be present in parents attending CAM. Alcohol and drug abuse may also be present in different levels in both perpetrators and victims in CAM.
Three models are commonly used to explain the alcohol–IPV link. Alcohol can be a direct influence on violence because of aggravated aggression due to intoxication. This proximal effects model has been supported in studies. If partners are unhappy and live in dysfunctional relationships, alcohol misuse may again have an indirect association with partner violence. This indirect effects model, however, has been questioned in studies. The third model states that the association between alcohol and IPV is explained by other background factors such as personality disorders. This spurious model has found little support in studies (Foran & O'Leary, 2008).
Child abuse
Low socioeconomic status has been acknowledged as a strong correlate to child abuse in many studies, and it specifically links to unemployment (Cicchetti & Valentino, 2006). Other factors related to child maltreatment are community violence and social isolation.
Parental characteristics. On the psychological level, parental depression and lack of impulse control are linked to child maltreatment (Cicchetti & Valentino, 2006). Parents with these traits are less satisfied with their children overall. They perceive negative intentions in their children. They talk less with them and have unrealistic expectations of them. Instead of talking and reasoning, they will use inappropriate discipline practices.
Very few studies have documented the associations between psychopathology in parents and child abuse. In a sample of 300 parents accused of physical abuse or neglect, undergoing psychological evaluations, 64 % had a personality disorder (Bogacki & Weiss, 2007). Another study compared parental psychopathology in parents (mothers or fathers) accused of physical abuse or neglect with a control group of parents not formally accused by the child protection services. No differences were seen between the two maltreating groups, but abusive and neglectful parents had more personality disorders, more alcohol abuse, lower income, and more social isolation than the control group (Fontaine & Nolin, 2012).
Family factors. Disruptive relationships, anger, and conflicts and dissatisfaction in marriage are some of the features of maltreating families. Family systems theory explains the disruptions in structure, processes, and communication. Hierarchies and subsystems (e.g. parents, siblings) may be malfunctioning and communication disrupted. A disorganized family structure is typical in maltreating families (Cicchetti & Valentino, 2006).
Child characteristics. Children with chronic diseases and disabilities are more often abused than children with no such diseases or disabilities (Janson et al., 2011; Sullivan & Knutson, 2000). This association may be dependent on stress in parents, increased demands of parenting, and deficiency of support for families with disabled children (Svensson, 2013). In a Swedish study the presence of chronic diseases/conditions, in particular for those not born in Sweden, were a risk factor for physical abuse (Svensson, Bornehag, & Janson, 2011).
Etiology of double exposure
A few studies have found risk factors on the individual, family, and environment levels in families with double exposure (Robinsson, 2014). These studies include samples from the general population, but also from families charged with child maltreatment or with substantiated reports from the criminal justice system. Male perpetrators of both child abuse and IPV more often use drugs (Beeman, Hagemeister, & Edleson, 2001; Dixon, Hamilton-Giachritsis, Browne, & Ostapuik, 2007; Hartley, 2002; Tajima, 2004) and more often have been convicted for non-domestic violent crimes (Dixon et al., 2007; Hartley, 2002; Slep & O’Leary, 2009) than men who engage in only one form of family violence. In families with double exposure, mental health problems are more common in both men and women than in families where only one form of violence occurs (Dixon et al., 2007; Hartley, 2002; Slep & O’Leary, 2009; Tajima, 2004), as are lower education and being a childhood victim of abuse (Lévesque, Clément, & Chamberland, 2007). Some studies found higher stress levels in both male and females in families with double exposure (Dixon et al., 2007; Tajima, 2004), but others did not (Coohey, 2004; Lévesque et al., 2007).
Studies of the etiology of double exposure are still at an early stage. Samples typically studied from the perspective of criminology may generate different results from those of the general population. Different levels of severity may also influence the results.
Consequences of child abuse and IPV on child development and psychopathology
Child abuse and exposure to IPV affects children in both high-income and low-income countries. Both short- and long-term consequences have been documented. Double exposure is not unusual and has more negative effects than either child abuse or IPV on its own. How can we understand the reactions of children growing up in a harmful environment? Theoretical models help both policy makers and clinicians to work toward prevention and intervention for these children. Several theories describe the interplay between the environment and the adaptive or maladaptive development of children living abusive relations.Theoretical aspects
Developmental psychopathology.
(Cicchetti & Tooth, 1995, p. 542). Psychopathology in children should be studied and compared with normal or adaptive behavior at a particular stage in the child’s development. It is important to consider the influence the child’s internal development and external factors have on each other. For example, if a parent who experienced IPV appealed for comfort and help from her teenage daughter, this would probably have a specific effect on the daughter’s individuation process, a core developmental task at that age. The ability to develop an identity independent of parental needs will be difficult. If this developmental task is not solved, there is a risk for individual or relational problems in dating or mating in the future. At this stage in the child’s specific developmental process, the actual exposure to intimate violence and the parent’s capacity to handle the situation will determine the adaptive or maladaptive behaviors in the child. The paradigm of developmental psychopathology takes into account that the child, parent, and environment are constantly changing. A certain type of violence may result in distinct difficulties for the child at varying times and contexts in the developmental process. Attachment theory conceptualizes the consequences of abuse and IPV through the impact these experiences have on the child’s attachment to caregivers, both abusive and victimized. Social learning theory stresses how children learn and imitate aggressive behavior. The perspective of psychological trauma suggests that a frightening experience can result in specific trauma symptoms, affecting emotions, behavior, and other attributes. An overview of these theories will be presented below.
Attachment theory
needs, an insecure attachment may develop. When the child expresses fear, a normal parental reaction is to comfort. But in insecure attachment relationships, a parent may instead reject the child. Rejection can be open and conscious or more subtle and unconscious on the part of the parent. Children are especially vulnerable to disruptions in the attachment relationship during the first years of their life.
If the parent behaves in a frightening manner, for example in the case of abuse or IPV, the child is in a very difficult and paradoxical situation because the caregiver, who is supposed to be a source of comfort, may now be a source of danger (Kobak & Madsen, 2008). The impulse to seek proximity to the caregiver does not cease, even if the parent is frightening or frightened. Thus the child is caught in a struggle between two opposing forces: to approach the attachment figure while avoiding or even fleeing from the frightening parent. The child then loses both parents as a secure haven and has no way to meet its need for protection and is left in a state of fright without solution (Hesse & Main, 2006). This disorganized attachment was described by Main and Solomon in 1990 (Broberg, Risholm Mothander, Granqvist, & Ivarsson, 2008). This type of attachment can develop if a parent is abusive towards the child, but also if a parent is victimized and lives in fear (Kobak & Madsen, 2008). The child is at risk of developing disorganized attachment also if a victimized parent becomes depressed, dissociative, or neglectful towards the child. Disorganized attachment relations are predictive in particular of externalizing problems and to a lesser degree of internalizing problems according to two meta-studies (Fearon, Bakermans-Kranenburg, Van Ijzendoorn, Lapsley, & Roisman, 2010; Groh, Roisman, van Ijzendoorn, Bakermans-Kranenburg, & Fearon, 2012). Disorganized attachment is also related to aggressive behavior against peers later in childhood. Hostility towards partners in young adults is another consequence of disorganized attachment (Hesse & Main, 2006).
(with or without psychotherapy) from insecure to secure. Secure attachment to at least one parent can buffer the risk of developing externalizing problems (Kochanska & Kim, 2013).
Social learning theory.
Abused children may themselves become aggressive, as documented in many studies (Gilbert et al., 2009). The central idea in social learning theory is that children (and adults) learn behaviors by observation and reproduce them via symbolic representations. The theory draws from both behaviorism and cognitive theory (Grusec, 1992). In this process, called modelling, children will imitate the behaviors of significant others if those behaviors are rewarding. Passer and Smith wrote that “people learn by observing the behavior of models and acquiring the belief that they can produce behaviors to influence events in their lives” (2007, p. 225). Violence watched or experienced at home may be imitated by the child when interacting with peers or other people. To gain advantages or toys, children may use aggression in an instrumental way. A child who is attacked may in turn use aggression instead of other tactics to calm the tense situation. In verbal conflicts, the child may use aggression in an early state of argumentation instead of solving the conflict with words.
Observational learning occurs in four steps: (1) the child attends to a behavior performed by an important person, e.g. a parent; (2) the child remembers the behavior; (3) the child imitates the behavior; and (4) the child is rewarded for the behavior. For example if the father hits the mother, this action can be reproduced, e.g. the child can hit a doll or a friend. The observed behavior will be reproduced with greater probability if there is an incentive linked to the behavior. If the father’s violent acts generate certain advantages, the child may think that reproducing this behavior will generate similar advantages. When children judge that they can accomplish a goal, this will motivate them to exert a certain behavior. This process is called self-efficacy.
Trauma theory
stage, and the interpretations of preschool children differ from those of older children and adults (American Psychiatric Association, 2013).
The PTSD diagnosis includes an external event under the definition’s syndrome section. Domestic violence, sexual abuse, and physical abuse are all listed as possible events. The disorder can be long-lasting, especially if the stressor is interpersonal and intentional (e.g., torture, sexual violence) (American Psychiatric Association, 2013). Risk factors for developing PTSD are, among others, lower socioeconomic status, lower education, exposure to prior trauma, childhood adversity (e.g. economic deprivation, family dysfunction, parental separation, and death), minority status, and family psychiatric history.
Trauma theory. Recurrent memories from a traumatic event will trigger a stress response when a person is confronted with a reminder of the event. Increased arousal such as irritability and anger will occur. Such trauma symptoms from these two clusters have been explained as a dysregulation of the stress response or “allostatic overload” (Gunnar & Quevedo, 2007). Chronic stress in early childhood can make children hypersensitive to stress stimuli. Such easily elevated stress levels will negatively impact both the body and the brain.
The dual representation theory is based on memory research (Brewin, 2001). According to this theory traumatic memories are dysfunctionally stored in the amygdala and not directly accessible for language. The memories are only accessible via situational cues, and no inhibitory functions can influence the recall. The connection between traumatic memories and cortical structures in the brain are weak and thus out of conscious control.
Yet, another theory of trauma is the cognitive model of PTSD by Ehlers and Clark (Smith, Perrin, Yule, & Clark, 2010). When confronted with danger, children (and adults) will over-generalize the possibility of similar traumatic events reoccurring, which will result in anxiety or fear. Mistaken beliefs about the cause of the traumatic event can result in exaggerated guilt or responsibility for the events. These negative appraisals will extend to false interpretations of symptoms and the reactions of people in the proximity.
